Download Management of Varicose Veins

Management of Varicose Veins
Richard H. Jones, MD, MSPH, Naval Health Clinic, Quantico, Virginia
Peter J. Carek, MD, MS, Medical University of South Carolina, Charleston, South Carolina
Varicose veins are twisted, dilated veins most commonly located on the lower extremities. Risk factors include chronic
cough, constipation, family history of venous disease, female sex, obesity, older age, pregnancy, and prolonged standing. The exact pathophysiology is debated, but it involves a genetic predisposition, incompetent valves, weakened
vascular walls, and increased intravenous pressure. A heavy, achy feeling; itching or burning; and worsening with
prolonged standing are all symptoms of varicose veins. Potential complications include infection, leg ulcers, stasis
changes, and thrombosis. Some conservative treatment options are avoidance of prolonged standing and straining,
elevation of the affected leg, exercise, external compression, loosening of restrictive clothing, medical therapy, modification of cardiovascular risk factors, reduction of peripheral edema, and weight loss. More aggressive treatments
include external laser treatment, injection sclerotherapy, endovenous interventions, and surgery. Comparative treatment outcome data are limited. There is little evidence to preferentially support any single treatment modality. Choice
of therapy is affected by symptoms, patient preference, cost, potential for iatrogenic complications, available medical
resources, insurance reimbursement, and physician training. (Am Fam Physician. 2008;78(11):1289-1294. Copyright
© 2008 American Academy of Family Physicians.)
V
aricose veins are generally identified by their twisted, bulging,
superficial appearance on the
lower extremities. They also can
be found in the vulva, spermatic cords (varicoceles), rectum (hemorrhoids), and esophagus (esophageal varices).1 Varicose veins
are a common problem, with widely varying
estimates of prevalence. In general, they are
found in 10 to 20 percent of men and 25 to
33 percent of women.2,3
Etiology
The etiology of varicose veins is multifactorial
and may include: increased intravenous pressure caused by prolonged standing; increased
intra-abdominal pressure arising from tumor,
pregnancy, obesity, or chronic constipation;
familial and congenital factors; secondary vascularization caused by deep venous
thrombosis; or less commonly, arteriovenous
shunting.4 Shear forces and inflammation
have recently been recognized as important
etiologic factors for venous disease.5
Venous disease resulting in valve reflux
appears to be the underlying pathophysiology for the formation of varicose veins.
Rather than blood flowing from distal to
proximal and superficial to deep, failed or
incompetent valves in the venous system
allow blood to flow in the reverse direction.
With increased pressure on the local venous
system, the larger affected veins may become
elongated and tortuous. Although no specific
etiology is noted, in most cases the valvular
dysfunction is presumed to be caused by a
loss of elasticity in the vein wall, with failure
of the valve leaflets to fit together.6
Diagnosis
CLINICAL PRESENTATION
The clinical presentation of varicose veins
varies among patients.7 Some patients are
asymptomatic. Symptoms, if present, are
usually localized over the area with varicose
veins; however, they may be generalized to
include diffuse lower extremity conditions.
Localized symptoms include pain, burning,
or itching. Generalized symptoms consist of
leg aching, fatigue, or swelling. Symptoms are
often worse at the end of the day, especially
after periods of prolonged standing, and
usually disappear when patients sit and elevate their legs. Women are significantly more
likely than men to report lower limb symptoms, such as heaviness or tension, swelling,
aching, restless legs, cramps, or itching.8
No correlation between the severity of the
varicose veins and the severity of symptoms
has been noted. Established risk factors for
varicose veins include chronic cough, constipation, family history of venous disease,
Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 2008 American Academy of Family Physicians. For the private, noncommercial
use of one individual user of the Web site. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests.
SORT: Key Recommendations For Practice
Clinical recommendation
Conservative therapy (e.g., elevation, external compression devices,
butcher’s broom, horse chestnut seed extract, weight loss) for varicose
veins may be helpful, but there are few clinical trials.
There is insufficient evidence to preferentially recommend any specific
treatment or combination of treatments for varicose veins.
Sclerotherapy may be used to improve the symptoms and cosmetic
appearance of varicose veins.
Evidence
rating
References
C
13-16
B
12, 13, 15,
22, 29
29
B
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented
evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information
about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml.
female sex, obesity, occupations associated
with orthostasis, older age, pregnancy, and
prolonged standing.9
Although varicose veins may cause varying degrees of discomfort or cosmetic
concern, they are rarely associated with significant medical complications. Skin pigmentation changes, eczema, infection, superficial
thrombophlebitis, venous ulceration, loss of
subcutaneous tissue, and a decrease in lower
leg circumference (lipodermatosclerosis) are
possible complications. Although rare, external hemorrhage resulting from the perforation of a varicose vein has been reported.10
Evaluation of patient risk factors, symptoms, and typical physical examination findings help determine a diagnosis. Although a
detailed physical examination is sufficient to
diagnose most patients with primary varicose
veins, it does not provide information about
the presence of deep venous insufficiency.
Clinical tests used to detect the site of reflux are
of limited value (Table 1).11 A positive tap test
and negative Perthes test are most helpful.11
IMAGING STUDIES
Imaging studies are generally not necessary for
diagnosis, but they may be useful in patients
with severe symptoms or in patients who are
obese. They also may be helpful for planning
procedures, documenting the extent of vascular pathology, or identifying the source
of venous reflux. Duplex Doppler ultrasonography is a simple, noninvasive, painless,
readily available modality that can assess the
anatomy and physiology of the lower extremity venous system. It can evaluate for acute
and occult deep venous thrombosis, superficial thrombophlebitis, and reflux at the
1290 American Family Physician
www.aafp.org/afp
saphenofemoral and saphenopopliteal junctions. It can also assess the competence and
diameter of the greater and lesser saphenous
veins and the vascular architecture of the
tributary and deeper perforating veins. Other
less commonly used studies that may be helpful in select patients include venography, light
reflex rheography, ambulatory venous pressure measurements, photoplethysmography,
air plethysmography, and foot volumetry.
Treatment
Treatment options for varicose veins include
conservative management, external laser
treatment, injection sclerotherapy, endovenous interventions, and surgery (Table 2).12
The indications for treatment are largely
based on patient preference. Choice of treatment is also affected by symptoms, cost,
potential for iatrogenic complications, available medical resources, insurance reimbursement, and physician training, as well
as the presence or absence of deep venous
insufficiency and the characteristics of the
affected veins. Vascular surgical intervention
for venous insufficiency may be indicated in
patients with aching pain and leg fatigue,
ankle edema, chronic venous insufficiency,
cosmetic concerns, early hyperpigmentation, external bleeding, progressive or painful ulcer, or superficial thrombophlebitis.
CONSERVATIVE MANAGEMENT
Conservative treatment options include
avoidance of prolonged standing and
straining, elevation of the affected leg,
exercise, external compression, loosening
of restrictive clothing, medical therapy,
modification of cardiovascular risk factors,
Volume 78, Number 11
◆
December 1, 2008
Table 1. Clinical Tests Used to Detect Venous Reflux in Patients with Varicose Veins
Sensitivity
(%)
Specificity
(%)
Positive
predictive
value (%)
Negative
predictive
value (%)
Test
Description
Finding
Tap test
With the patient
standing, a hand
is placed over the
SFJ, and the LSV is
tapped at the level
of the knee with the
other hand.
18
92
70
47
Cough test
With the patient
standing, a finger is
placed on the thigh
over the SFJ.
With the patient
standing, a
tourniquet is applied
below the knee.
The patient is directed
to complete 10 heel
raises.
With the patient in
the supine position,
the affected leg is
elevated to
45 degrees to drain
the varicosities.
A tourniquet is
applied just below
the SFJ, and the
patient is directed to
stand.
A palpable transmitted
impulse denotes that the
LSV is distended with blood.
The SFJ is then tapped
and the presence of a
retrograde, palpably
transmitted impulse
at the knee indicates
incompetence of valves
between the SFJ and the
LSV, with reflux in the
proximal LSV.
A palpable thrill or impulse on
coughing is indicative of an
incompetent SFJ.
59
67
64
38
If the varicosities empty, the
site of reflux is above the
tourniquet.
If the veins remain distended,
the site of reflux is below
the tourniquet.
97
20
55
13
Failure of the varicosities to fill
indicates that the SFJ is the
site of reflux.
91
15
52
38
Perthes test
Trendelenburg
test
NOTE:
Assume a pretest probability of 50 percent, and use duplex Doppler ultrasonography as the reference standard.
LSV = long saphenous vein; SFJ = saphenofemoral junction.
Information from reference 11.
reduction of peripheral edema, and weight
loss. External compression devices (e.g.,
bandages, support stockings, intermittent
pneumatic compression devices) have been
recommended as initial therapy for varicose
veins; however, evidence to support these
therapies is lacking.13 Typical recommendations include wearing 20 to 30 mm Hg
elastic compression stockings with a gradient of decreasing pressure from the distal to
proximal extremity.14
Multiple medications have been proposed
as treatments for varicose veins. The use
of diuretics is not supported by medical
December 1, 2008
◆
Volume 78, Number 11
literature. Horse chestnut seed extract
(Aesculus hippocastanum) has been used in
Europe and has been shown in randomized,
double-blind, placebo-controlled trials to
reduce edema.15 Butcher’s broom (Ruscus
aculeatus) has also been used; however, clinical data to establish its safety and effectiveness are lacking.16
EXTERNAL LASER TREATMENT
Multiple laser machines that deliver various
wavelengths of light through the skin and
into the blood vessels are available to treat
varicose veins. The light is absorbed in the
www.aafp.org/afp
American Family Physician 1291
Varicose Veins
Table 2. Treatment Options for Varicose Veins
Treatment options
Conservative measures
Compression (e.g., bandages,
support stockings,
intermittent pneumatic
compression devices)
Elevation of the affected leg
Comments
Support stockings can provide relief from
discomfort.
Elevation may improve symptoms in
some patients.
Lifestyle modifications
Examples include avoidance of prolonged
standing, exercise, loosening of
restrictive clothing, modification
of cardiovascular risk factors, and
reduction of peripheral edema.
Weight loss
Weight loss may improve symptoms in
patients who are obese.
Endovenous or interventional therapy
Endovenous obliteration
Randomized controlled trials comparing
clinical effectivenss and costExternal laser therapy
effectiveness are lacking.
Sclerotherapy
Surgery
Ligation
Historically, surgery has been
the most widely recommended
Phlebectomy
treatment option.
Stripping
endothelium, sealing and scarring the vein.
A variety of products are used, including
hyperosmotic solutions (e.g., hypertonic
saline), detergent solutions (e.g., sodium tetradecyl sulfate), and corrosive agents (e.g.,
glycerin). Injections typically work better
on small (1 to 3 mm) and medium (3 to
5 mm) veins; however, a precise diameter
used to make treatment decisions is lacking.
Although sclerotherapy is a clinically effective and cost-effective treatment for smaller
varicose veins, concerns about the development of deep venous thrombosis and visual
disturbances, and the recurrence of varicosities have been noted.12,18,19
ENDOVENOUS OBLITERATION OF THE
SAPHENOUS VEIN
A newer treatment for varicose veins is to
insert a long, thin catheter that emits energy
(most commonly heat, radio waves, or laser
energy). The released energy collapses and
scleroses the vein. A variety of techniques
and protocols are used. Because it is easier to
insert a catheter through a vein in the same
direction that the valves open, the catheter is
Information from reference 12.
most commonly inserted into a more distal
portion of the vein and threaded proximally.
Energy is released from the catheter tip. As
vessels by hemoglobin, leading to thermoco- the catheter is pulled out, the vein lumen colagulation. Types of lasers include pulsed dye, lapses. Bruising, tightness along the course
long pulsed, variable pulsed, neodymium- of the treated vein, recanalization, and pardoped yttrium aluminum garnet (Nd:YAG), esthesia are possible complications.20,21
and alexandrite lasers. Potentially, any
small, straight vein branch is amendable to SURGERY
external laser ablation. However, laser ther- Historically, surgery is the best known treatapy has typically been used on telangiecta- ment for varicose veins, especially when the
sias and smaller vessels rather than on larger greater saphenous vein is involved. Howveins. Long-pulsed lasers have been shown ever, literature does not consistently support
to completely clear veins with diameters less surgery as the definitive treatment option.22
than 0.5 mm. For veins with diameters of Most surgical techniques involve using mul0.5 to 1.0 mm, improvement but not clear- tiple smaller incisions to reduce scarring,
ance is achieved.17
blood loss, and complications.
Surgical management may reduce the risk
SCLEROTHERAPY
of complications of varicose veins. SurgiSclerotherapy involves injecting superficial cal correction of superficial venous reflux
veins with a substance that causes them to reduces 12-month ulcer recurrence.23 In
collapse permanently. A needle is inserted addition, surgical management of venous
into the vein lumen and a sclerosing sub- ulcers leads to an 88 percent chance of ulcer
stance is injected. The substance displaces healing, with only a 13 percent risk of ulcer
the blood and reacts with the vascular recurrence over 10 months.24
1292 American Family Physician
www.aafp.org/afp
Volume 78, Number 11
◆
December 1, 2008
Varicose Veins
The simplest surgical procedure is ligation, which involves tying off the enlarged
vein in portions of the leg, thigh, and groin.
Potential complications include recurrence
and worsening of intravenous pressure in
tributary veins.
Phlebectomy and stripping are probably
the best known procedures; however, they
are more of a collection of procedures than
single techniques. For phlebectomy, the varicose vein is mapped and marked on the skin
using visual skin changes or duplex Doppler
ultrasonography while the patient is standing. The patient is then placed in a supine
position, and a series of perpendicular 1- to
2-mm stab incisions are made over the vein
several centimeters apart. The saphenous
vein is identified in the groin, brought to the
surface via a small incision, and ligated. The
vein is hooked and brought to the surface at
the next incision site. It is then pulled and
dissected proximally and distally at each
incision site to release it from the surrounding tissues and to sever any connections to
tributary or deeper perforating veins. This
process is repeated distally. The vein can
be removed in a long strip or in multiple
smaller pieces depending on the size and
shape of the vessels, as well as the patient’s
vascular pathology.25,26 Alternatively, the
greater saphenous vein can be ligated and
incised at the groin. A stripper is inserted
into the vein near the knee and moved proximally. The stripper is then attached to the
proximal end of the vein and pulled distally,
removing it.5,27
Typically, surgical procedures are done
in a hospital operating room or in an outpatient surgical center. These procedures
are associated with significant cost and risk
of complications from anesthesia. Potential
postsurgical complications include bleeding,
bruising, and infection. In addition, a new
blood vessel may form after the procedure,
with the risk of neovascularization estimated
to be as high as 15 to 30 percent.5
symptoms, the extent of vascular pathology, and the available resources. For example,
12-month ulcer recurrence
rates are significantly reduced
in patients treated with compression and surgery compared with those treated with
compression alone.23 A specific
combination or standard protocol
currently be recommended.
Studies of treatments for
varicose veins are limited
by small numbers of study
participants, short followup, and inconsistent end
points.
cannot
Outcome Data
Studies of treatments for varicose veins are
limited by small numbers of study participants, short follow-up, and inconsistent end
points (e.g., resolution of symptoms, ultrasonography measurements, appearance as
judged by the patient or physician).
Three Cochrane systematic reviews of
varicose vein treatment exist.22,28,29 The
first compared surgery and sclerotherapy.
Although nine randomized controlled trials (RCTs) fulfilled inclusion criteria, there
was insufficient evidence to recommend
any single therapy. A trend of better results
with sclerotherapy after one year was noted.
Beyond one year, and especially after three
to five years, better outcomes were noted
with surgery.22
The second Cochrane systematic review
evaluated the use of a tourniquet during
surgery to minimize blood loss. It included
three small RCTs. Differences in study
design, outcome measures, and analysis
precluded pooling the data for a meta-
analysis. The authors concluded that a tourniquet appeared to reduce blood loss during
surgery.28
The third Cochrane systematic review
compared sclerotherapy and graduated compression stockings or observation. Complication and recurrence rates were reviewed,
as were improvements in symptoms and cosmetic appearance. Sclerotherapy was effective in reducing symptoms and appearance of
varicose veins. However, the RCTs that were
COMBINATION THERAPY
included showed that the type of sclerosant,
Combinations of conservative measures local pressure dressing, or degree and length
and more invasive techniques may be of compression had no significant impact on
appropriate, depending on the patient’s the effectiveness of sclerotherapy.29
December 1, 2008
◆
Volume 78, Number 11
www.aafp.org/afp
American Family Physician 1293
Varicose Veins
The Authors
RICHARD H. JONES, MD, MSPH, is a private health care
consultant in Alexandria, Va. At the time of writing this
article, he was a family physician at the Naval Health Clinic
in Quantico, Va. Dr. Jones received his medical degree from
the University of North Carolina at Chapel Hill School of
Medicine and a master of science in public health degree
from Tulane University School of Public Health and Tropical Medicine in New Orleans, La. He completed a family
medicine residency at the Medical University of South
Carolina (MUSC) in Charleston.
PETER J. CAREK, MD, MS, is the director of the Trident/
MUSC Family Medicine Residency Program and a family medicine professor at MUSC. He received his medical
degree from MUSC and a master of science degree from
the University of Tennessee in Knoxville. Dr. Carek also
completed a family medicine residency at MUSC and a
sports medicine fellowship at the University of Tennessee
Graduate School of Medicine.
Address correspondence to Richard H. Jones, MD, MSPH,
106 W. Howell Ave., Alexandria, VA 22301. Reprints are
not available from the authors.
Author disclosure: Nothing to disclose.
REFERENCES
1. London NJ, Nash R. ABC of arterial and venous disease.
Varicose veins. BMJ. 2000;320(7246):1391-1394.
2. Callam MJ. Epidemiology of varicose veins. Br J Surg.
1994;81(2):167-173.
3. Bergan JJ, Sparks SR, Owens EL, Kumins NH. Growing
the vascular surgical practice: venous disorders. Cardiovasc Surg. 2001;9(5):431-435.
4. Sadick NS. Advances in the treatment of varicose veins:
ambulatory phlebectomy, foam sclerotherapy, endovascular laser, and radiofrequency closure. Dermatol Clin.
2005;23(3):443-455.
5. Bergan JJ, Schmid-Schönbein GW, Smith PD, Nicolaides
AN, Boisseau MR, Eklof B. Chronic venous disease.
N Engl J Med. 2006;355(5):488-498.
6. Clarke GH, Vaskedis SN, Hobbs JT, Nicolaides AN.
Venous wall function in the pathogenesis of varicose
veins. Surgery. 1992;111(4):402-408.
7. Teruya TH, Ballard JL. New approaches for the
treatment of varicose veins. Surg Clin North Am.
2004;84(5):1397-1417.
8. Bradbury A, Evans C, Allan P, Lee A, Ruckley CV,
Fowkes FG. What are the symptoms of varicose veins?
Edinburgh vein study cross sectional population survey.
BMJ. 1999;318(7180):353-356.
9. Beebe-Dimmer JL, Pfeifer JR, Engle JS, Schottenfeld D.
The epidemiology of chronic venous insufficiency and
varicose veins. Ann Epidemiol. 2005;15(3):175-184.
10. Racette S, Sauvageau A. Unusual sudden death: two
case reports of hemorrhage by rupture of varicose
veins. Am J Forensic Med Pathol. 2005;26(3):294-296.
11. Kim J, Richards S, Kent PJ. Clinical examination of varicose
1294 American Family Physician
www.aafp.org/afp
veins—a validation study. Ann R Coll Surg Engl.
2000;82(3):171-175.
12. Campbell B. Varicose veins and their management.
BMJ. 2006;333(7562):287-292.
13. Bartholomew JR, King T, Sahgal A, Vidimos AT. Varicose
veins: newer, better treatments available. Cleve Clin J
Med. 2005;72(4):312-314, 319-321, 325-328.
14. L am Ey, Giswold ME, Moneta GL. Venous and lymphatic
disease. In: Schwartz’s Principles of Surgery. 8th ed.
New York, NY: McGraw-Hill, 2005:823-825.
15. Diehm C, Trampisch HJ, Lange S, Schmidt C. Comparison of leg compression stocking and oral horse-chestnut seed extract therapy in patients with chronic venous
insufficiency. Lancet. 1996;347(8997):292-294.
16. Mashour NH, Lin GI, Frishman WH. Herbal medicine for
the treatment of cardiovascular disease: clinical considerations. Arch Intern Med. 1998;158(20):2225-2234.
17. Reichert D. Evaluation of the long-pulse dye laser for
the treatment of leg telangiectasias. Dermatol Surg.
1998;24(7):737-740.
18. Gibson KD, Ferris BL, Pepper D. Endovenous laser
treatment of varicose veins. Surg Clin North Am.
2007;87(5):1253-1265.
19. Weiss MA, Weiss RA. Sclerotherapeutic agents available
in the United States and elsewhere. In: Goldman MP,
Bergan JJ. Ambulatory Treatment of Venous Disease: An
Illustrative Guide. St. Louis, Mo.: Mosby;1996:37-48.
20. Merchant RF, DePalma RG, Kabnick LS. Endovascular
obliteration of saphenous reflux: a multicenter study.
J Vasc Surg. 2002;35(6):1190-1196.
21. Min RJ, Khilnani N, Zimmet SE. Endovenous laser treatment of saphenous vein reflux: long-term results. J Vasc
Interv Radiol. 2003;14(8):991-996.
22. Rigby KA, Palfreyman SJ, Beverley C, Michaels JA.
Surgery versus sclerotherapy for the treatment of
varicose veins. Cochrane Database Syst Rev. 2004;(4):
CD004980.
23. Barwell JR, Davies CE, Deacon J, et al. Comparison of
surgery and compression with compression alone in
chronic venous ulceration (ESCHAR study): randomised
controlled trial. Lancet. 2004;363(9424):1854-1859.
24. Tenbrook JA Jr, Iafrati MD, O’Donnell TF Jr, et al. Systemic review of outcomes after surgical management
of venous disease incorporating subfascial endoscopic
perforator surgery. J Vasc Surg. 2004;39(3):583-589.
25. Ricci S, Georgiev M, Goldman M. Phlebectomy. In:
Ambulatory Phlebectomy: A Practical Guide for Treating Varicose Veins. St. Louis, Mo.: Mosby;1995:79-122.
26. Bergan JJ. Ambulatory surgery of varicose veins. In:
Goldman MP, Bergan JJ. Ambulatory Treatment of
Venous Disease: An Illustrative Guide. St. Louis, Mo.:
Mosby;1996:149-154.
27. Angle N, Bergan JJ. Varicose veins: chronic venous
insufficiency. In: Moore WS, ed. Vascular Surgery:
A Comprehensive Review. 5th ed. Philadelphia, Pa.:
Saunders;1998:800-807.
28. Rigby KA, Palfreyman SJ, Beverly C, Michaels JA. Surgery for varicose veins: use of tourniquet. Cochrane
Database Syst Rev. 2002;(4):CD001486.
29. Tisi PV, Beverley C, Rees A. Injection sclerotherapy for
varicose veins. Cochrane Database Syst Rev. 2006;(4):
CD001732.
Volume 78, Number 11
◆
December 1, 2008